经尿道膀胱颈六点锚定铥激光直视推拨法前列腺整体剜除术治疗大体积BPH的疗效和学习曲线分析

Efficacy and learning curve of Thulium laser enucleation of the prostate by laser controller anchored at six o'clock position of bladder neck in the treatment of BPH with large gland

目的探讨经尿道膀胱颈六点锚定激光直视推拔法前列腺整体除术(LC-THuLEP)治疗大体积(>80ml)良性前列腺增生(BPH)的疗效和学习曲线。方法回顾性分析2022年1-10月上海市东方医院同一术者应用经尿道膀胱颈六点锚定LC-THuLEP治疗的第1~45例大体积BPH患者的临床资料。按照手术开展时间的先后顺序分为A、B、C共3组,每组15例。A、B、C组患者年龄[(71.8±9.4)岁与(73.5±8.2)岁与(71.4±5.5)岁]、前列腺体积[88.3(84.8,100.6)ml与91.5(86.1,118.4)ml与94.5(84.7,101.8)ml]、前列腺特异性抗原(PSA)[4.8(2.9,8.5)ng/ml与7.2(3.2,11.2)ng/ml与7.8(4.5,12.7)ng/ml]、残余尿量[44.0(34.0,67.0)ml与60.0(40.0,76.0)ml与39.0(0,59.0)ml]、最大尿流率(Qmx)[8.4(7.6,11.1)ml/s与8.6(6.5,10.6)ml/s与10.4(7.8,13.2)ml/s]、国际前列腺症状评分(IPSS)[20(18,21)分与20(20,22)分与20(20,25)分[生活质量评分(Q0L)[4(4,5)分与4(4,4)分与4(3,5)分]差异均无统计学意义(P>0.05)。术者有>100例经尿道前列腺电切术(TURP)手术经验。经尿道膀胱颈六点锚定LC-THuLEP方法:应用激光操作架直视推拨腺体时,膀胱颈部6点预留0.5~1.0cm不离断,作为“锚”固定前列腺膀胱颈部,使剥离的腺体不转晃,最后切割膀胱颈6点处的前列腺腺体,实现前列腺整体刻除。比较3组的手术效果和术后并发症。用刻除的前列腺组织质量除以刻除时间计算刻除效率。结果A、B、C组的手术时间[100.0(90.0,110.0)min与80.0(70.0,90.0)min与75.0(70.0,90.0)min、刻除时间[89.0(72.0,97.0)min与67.0(64.0,77.0)min与64.0(60.0,77.0)min]、刻除效率[0.65(0.62,0.68)g/min与0.84(0.83,0.94)g/min与0.93(0.82,1.00)g/min)差异均有统计学意义(P<0.05),B、C组的手术时间和除时间均显著低于A组,刻除效率显著高于A组(均P<0.05),但B、C组之间差异无统计学意义(P>0.05)。A、B、C组患者血红蛋白下降值[8.0(5.0,11.0)g/L与7.0(2.0,10.0)g/L与11.0(4.0,16.0)g/L)、留置导尿管时间[4.0(2.0,6.0)d与6.0(3.0,7.0)d与4.0(3.0,6.0)d)差异均无统计学意义(P>0.05)。所有患者术后6个月均获得随访,A、B、C组患者的Qmax[23.2(21.0,25.1)ml/s与22.7(21.1,26.1)ml/s与22.9(21.5,25.7)ml/s]、IPSS[6(5,8)分与7(6,8)分与7(7,8分]、Q0L[2(1,2)分与2(1,2)分与2(1,2)分]、残余尿量[20.0(10.0,25.0)ml与22.0(15.0,25.0)ml与5.0(0,25.0)ml)与术前比较,均有明显改善(P<0.05),但3组之间比较差异均无统计学意义(P>0.05)。3组术后并发症发生率差异无统计学意义[26.7%(4/15)与20.0%(3/15)与20.0%(3/15),P>0.05]。结论经尿道膀胱颈六点锚定LC-THuLEP治疗大体积BPH疗效确切,对于有丰富TURP手术经验的医生经过15例后可达到学习曲线。

Objective To analyze the efficacy,safety and learning curve of Thulium laser enucleation of the prostate by laser controller(LC-THuLEP)anchored at six oclock position of the bladder neck in the treatment of benign prostatic hyperplasia(BPH)with large gland.Methods The clinical data of the 1st to 45th BPH cases with large gland(prostate volume>80 ml)treated by a doctor with LC-THuLEP anchored at six oclock position of bladder neck in Shanghai East Hospital from January to October 2022 were retrospectively analyzed.The patients were divided into groups A,B and C according to the order of operation time,with 15 cases in each group.There were no significant differences among the three groups(P>0.05)in age[(71.8±9.4)years old vs.(73.5±8.2)years old vs.(71.4±5.5)years old],prostate volume[88.3(84.8,100.6)ml vs.91.5(86.1,118.4)ml vs.94.5(84.7,101.8)ml],prostate specific antigen(PSA)[4.8(2.9,8.5)ng/ml vs.7.2(3.2,11.2)ng/ml vs.7.8(4.5,12.7)ng/ml],postvoid residual volume[44.0(34.0,67.0)ml vs.60.0(40.0,76.0)ml vs.39.0(0,59.0)ml],maximum urine flow rate(Qmax)[8.4(7.6,11.1)ml/s vs.8.6(6.5,10.6)ml/s vs.10.4(7.8,13.2)ml/s],international prostate symptom score(IPSS)[20(18,21)vs.20(20,22)vs.20(20,25)Jand quality of life(QL)[4(4,5)vs.4(4,4)vs.4(3,5)J.The doctor had more than 100 cases of TURP surgery experience.LC-THuLEP anchored at six oclock position of bladder neck was described as follows.The bladder neck at six oclock position is reserved 0.5-1.0 cm as an"anchor"to fix the prostatic bladder neck when the gland was pushed directly by the laser controller,preventing the detached prostate gland from turning.Finally the bladder neck was cut off at six oclock position,and the prostate was en-bloc removed.The effect of surgery and postoperative complications were compared.The enucleation efficiency was equal to the weight of prostate tissue removed divided by the time of enucleation.Results The differences among the three groups in operation time[100.0(90.0,110.0)min vs.80.0(70.0,90.0)min vs.75.0(70.0,90.0)min],enucleation time[89.0(72.0,97.0)min vs.67.0(64.0,77.0)min vs.64.0(60.0,77.0)min]and the efficiency of enucleation[0.65(0.62,0.68)g/min vs.0.84(0.83,0.94)g/min vs.0.93(0.82,1.00)g/min]were statistically significant(P<0.05).The operation time and enucleation time in groups B and C were significantly lower than those in group A,and the enucleation efficiency was significantly higher than that in group A(P<0.05),while there was no significant difference between group B and C.However,the difference of three groups in hemoglobin decrease[8.0(5.0,11.0)g/L vs.7.0(2.0,10.0)g/L vs.11.0(4.0,16.0)g/L]and catheter indwelling duration[4.0(2.0,6.0)d vs.6.0(3.0,7.0)d vs.4.0(3.0,6.0)d]were not statistically different(P>0.05).All patients were followed up for 6 months after surgery.In three groups,postoperative Qmx were 23.2(21.0,25.1)ml/s,22.7(21.1,26.1)ml/s and 22.9(21.5,25.7)ml/s,IPSS were 6(5,8),7(6,8)and 7(7,8),QOL were 2(1,2),2(1,2)and 2(1,2),postvoid residual volume were 20.0(10.0,25.0)ml,22.0(15.0,25.0)ml and 5.0(0,25.0)ml,respectively,which were all significantly different from that of pre-operation(P<0.05).However,there were no statistically significant differences in the postoperative indicators among the three groups(P>0.05).No statistical difference was found in postoperative complications among the three groups[26.7%(4/15)vs.20.0%(3/15)vs.20.0%(3/15),P>0.05].Conclusions LC-THuLEP anchored at six oclock position of bladder neck was an effective operation in the treatment of BPH with large gland,and the learning curve could be reached after 15 cases.